MEDICARE: DR. SANDIP R SHUKLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD10653	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972596716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDIP R SHUKLA MD

Provider Business Mailing Address
First Line	:	107 E GRUNDY ST
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-3613
Country	:	US
Telephone Number	:	931-455-2616
Fax Number	:	931-455-2280

Provider Business Practice Location Address
First Line	:	107 E GRUNDY ST
Second Line	:
City	:	TULLAHOMA
State	:	TN
Zip	:	37388-3613
Country	:	US
Telephone Number	:	931-455-2616
Fax Number	:	931-455-2280

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	07/08/2007

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